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Reducing the Burden of Injury: Advancing Prevention and Treatment
interventions relied heavily on changing individual behavior, primarily through education and persuasion. Partly in reaction to the perceived failure of health education, Haddon (1968) and others highlighted the importance of mechanical and environmental factors. What Haddon had in mind was an extension of injury prevention from one cell of the matrix in Figure 1.2 (pre-event, individual behavior) to all the cells. However, during the late 1960s and early 1970s, the pendulum swung in the other direction, and the developing injury field was characterized by a strong emphasis on environmental intervention (and passive protection) and a deep skepticism about the efficacy of behavioral intervention. This perspective has long been regarded as axiomatic in the literature, and behavioral perspectives (e.g., of economists or health educators) have often been discounted or strongly criticized. In recent years, however, this intellectual tension has receded and behavioral perspectives are now increasingly viewed as complementary rather than antagonistic to environmental perspectives. Since 1985, knowledge about human judgment and decision making has made significant advances, integrating the perspectives of cognitive psychologists and economists. People have also recognized that behavioral interventions may sometimes be cheaper and more cost-effective than environmental ones even if they are more circumscribed in scope. Moreover, educational efforts have increasingly focused on changing the behaviors of those with opportunities to influence policy, such as legislators and the media, rather than on merely educating for the purpose of changing individual behavior.
Like other fields in public health, such as infectious disease control and substance abuse prevention, the injury field is defined by a preventive mission. Injury specialists are not "neutral" about whether injuries occur or whether their impact is ameliorated. However, this mission must be pursued in a social and cultural context where the message (that injuries are preventable) competes for attention with other concerns and where people have widely divergent attitudes about what risks are acceptable or what interventions are appropriate. One sign of the maturation of the injury field is the growing appreciation of the ethical and cultural context of injury prevention and treatment.
Injury prevention is not free. All preventive interventions have costs, including possible trade-offs with other important social values. In the early years of the field, injury specialists were almost reflexively inclined toward regulation, particularly of consumer products and environmental risks. This orientation was understandable in light of the weaknesses of legal regulation at the time. In recent years, however, the field has begun to incorporate the perspectives of economists, particularly the need to consider all of the behavioral effects of an intervention, to measure costs, and to seek a reasonable balance between benefits and costs. A complementary phenomenon has also occurred within the allied disciplines, as some economists and public policy experts have embraced the perspectives and vocabulary of public health (Cook, 1991; Zimring and Hawkins, 1997).